1. Meeting PSC Stroke 7 Standard
Tool creation
Policy development
Process to improving care

2. Purpose of performing swallow screen (SS) by nursing (Perry, 2001):
Quickly identify overt dysphagia
Performed before ANYTHING PO
No withholding PO if pt passes screening
Failures ensure rapid SLP referral
Decrease unneeded Dysphagia Eval (DE) by SLP
Comprehensive nursing assessment

3. Purpose of performing SS…(cont.)
NOT DE (i.e., water only)
Screening for possibility of dysphagia
H2O less irritating if aspirated (DePippo, et al.,1992)
Less time consuming tool
5cc, 10cc, & 90cc of water
Improves communication between nursing and SLP

4. SS and Nursing Scope of Practice
MI Public Health Code are generic guidelines
MI does not have Nurse Practice Act
SS not specifically addressed
Must consider:
Basic formal nursing training
Professional experience
Continuing Ed programs with formal instruction
Infringement on trained SLP dedication, time & education

5. Process for Designing Protocol
Developed SS in 2004 before PSC certification
Collaboration between SLP and Stroke CNS
Combined several screening tools
Evidence based:
BSS study (‘98),
BDST (’92)
Kidd Water Test (“93)
SSA (’01)
Massey Bedside (’02)

6. Bedside Swallow Screen Performed by Nursing
Individual & small group education
Education performed ED & adult units by SLP & CNS
Staff concerns:
time issues
clinical expertise
SS confused with DE
confusion in documentation affects billing
RN/SLP scope of practice

7. Bedside Swallow Screen Performed by Nursing
HOB elevated 90 degrees to slow bolus entrance into pharynx and allows for maximum airway protection (Cherney, 1994)
No straws by nursing during screen
Straws increase risk of aspiration due to difficulty coordinating suck using oral pressure vs. inhalation (Logemann, 1998)

8. Bedside Swallow Screen Performed by Nursing
initially designed for stroke pts
where to document results?
different nursing forms each unit
stickers vs standardized location on forms
physician education
ordering appropriately
holding all PO (include meds) for failure
continuing ed & education of new employees

9. Process: Developed swallow screen Developed teaching tools (hand outs)
algorithm instruction card, sheets, short lecture
Addressed staff concerns during education
Maintain f/u with DM/ADM
Reward &/or recognition for performance

10. Process: Stroke CNS presence in ED
Add order & nursing policy # to TIA/Stroke Orders
Continued chart review & data sharing in meetings/postings
Update forms
SS added to standardized nursing notes & Stroke Care Plan (highlighted)

11. Process: Article in nursing newsletter
Added swallow screen pass/fail to neuro t sheet in ED
Educate admit/ED physicians
Reeducate during nursing competency programs
Continue feedback on performance to DM/ADMs
SLP & CNS developed research study to validate SS

12. Expanded Policy
PI Physician champion (Pneumonia Team) approved core team to review & redesign policy
Expanded to all patients at risk
Redesigned algorithm
Mandatory ed for adult med/surg unit nursing staff
Transparent data

13. Expanded Policy Computerized teaching module objectives:
Define & add complications of dysphagia
Specify high risk patient populations
Identify patients for whom SS is contraindicated
Describe proper SS procedure
Determine what constitutes failure of SS
Describe documentation of findings
Added scenarios & test questions

14. Performance Improvement
Continue to provide motivators:
frequent education
recognition
transparent data
ongoing prospective chart review
multidisciplinary rounds

15. Nursing Research Study: “Concordance Between Patient Bedside Swallow Screen and Dysphagia Evaluation Results Obtained from Neurological Nurses and Speech Pathologists”
Purpose:
compare staff nurse assessment with SLP &
look at influence of certain patient characteristics.
Validation of SHS SS
Endpoint:100 stroke patients consented
IRB approval

16. Nursing Research Study
Neuro nurses education 1 on 1 for reliability
Improved nursing and physician staff by in
Orders for SS from many physician services
Data collection by CNS and SLP
Patient collection from Neuro/Stroke ICU and Neuro Stepdown
Study abstract submitted to AHA ISC 2010